Healthcare Provider Details

I. General information

NPI: 1427212497
Provider Name (Legal Business Name): TINA TING-LI CHANG O.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 BOAR CIR
FREMONT CA
94539-6042
US

IV. Provider business mailing address

596 BOAR CIR
FREMONT CA
94539-6042
US

V. Phone/Fax

Practice location:
  • Phone: 510-579-6365
  • Fax:
Mailing address:
  • Phone: 510-579-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007274
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPT 13689 TPA
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1645
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: